Healthcare Provider Details

I. General information

NPI: 1255388740
Provider Name (Legal Business Name): BERT E BACHRACH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 10/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 HOSPITAL DRIVE
COLUMBIA MO
65212-0001
US

IV. Provider business mailing address

PO BOX 7687
COLUMBIA MO
65205-7687
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-6921
  • Fax: 573-884-8823
Mailing address:
  • Phone: 573-882-2259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2003017173
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: